Hang
Time
BERKS
For teens and
young adults with
special needs
2016-2017
www.easterseals.com/esep
HangTime
BERKS
Evening Recreation Program for kids age 12 through young adult
Kids will enjoy making new friends and spending time with others in a safe, nurturing,
supportive environment, while parents enjoy an evening of respite.
In Fall 2016 we will continue to meet at the Sinking Spring Family YMCA
REGISTER TODAY!
Session Dates:
Session 1: 9/23 - 11/11
Sinking Spring YMCA
Session 2: 12/16 - 2/3
Sinking Spring YMCA
Session 3: 3/3 - 4/21
Sinking Spring YMCA
Join us at the Sinking Spring Family YMCA for an evening of fun activities with access to the
Y’s state-of-the-art amenities. Basketball, soccer, kickball and yoga are some of the exciting
activities that are planned.
Time:
The program is staffed by young adults with the skills and training to provide the
behavioral, developmental and communication support necessary for the success of all
participants. The staffing ratio is 1:3. TSS and other support staff are welcome.
Sinking Spring Family YMCA
4920 Penn Avenue
Sinking Spring, PA 19608
Download an application today at our website: easterseals.com/esep
QUESTIONS?
Please contact Katelyn Olah
610-775-1431 ext. 402
[email protected]
6:00-8:00 p.m. Friday Nights
Location:
Cost:
$150 for each 8-week session
Berks Hang Time is for kids
age 12 through young adult
Individuals age 21+ are welcome
Easter Seals Eastern Pennsylvania provides exceptional services to people with disabilities and other special needs to ensure that
they and their families maximize their potential and have equal opportunities to live, learn, work and play in their communities.
TO REGISTER, PLEASE FILL OUT THIS FORM AND MAIL IT WITH YOUR CHECK TO:
Easter Seals, Berks Hang Time, 1501 Lehigh Street, Suite 201, Allentown, PA 18103
Participant’s Name:_____________________________________________________________________________ Participant’s Age:___________________________
Parent/Guardian Name:____________________________________________________________________________________________________________________
Address__________________________________________________________________________________________________________________________________
City, State and Zip:________________________________________________________________________________________________________________________
Phone:____________________________________________________ Email:_________________________________________________________________________
COST IS $150 PER SESSION: PLEASE CHECK SESSION OR SESSIONS YOU WILL BE ATTENDING:
q Session 1
q Session 2
q Session 3
q Enclosed is my check payable to Easter Seals Eastern PA for each session attending.
q I acknowledge that the cost per session is $150
Easter Seals Eastern Pennsylvania Program Application 2016-2017
BERKS Schedule
Please check the desired programs and calculate the total cost
Hang Time
Saturday Respite
Friday evenings, 6:00 – 8:00PM
8-week session costs $150
For teens/young adults
10AM – 4PM
Cost per session $65 first child, $55 each additional child
Ages 5 and older plus potty-trained siblings
 Session 1: September 23, 2016 – November 11, 2016
Location: Sinking Spring YMCA
 Session 2: December 16, 2016 – February 3, 2017
Location: Sinking Spring YMCA
 Session 3: March 3, 2017 – April 21, 2017
Location: Sinking Spring YMCA
Locations:
9/17/16 – 10/22/16 Camp Lily, intersection of Angora & List Road
11/12/16 – 3/25/17 Olivet Boys & Girls Club, 1161 Pershing Blvd.
4/8/17 – 5/27/17
Camp Lily, intersection of Angora & List Road
Cost:
Session 1 $150
$_______
Cost:
First child:
Session 2 $150
$_______
Session 3 $150
$_______
Additional children:
# of children ____ x # of sessions ____ x $55 = $_______
Total cost:
$_______
Total cost: $_______
Select sessions and indicate number who will attend:
 9/17/16
#____
 1/28/17
#____
 9/24/16
#____
 2/11/17
#____
 10/8/16
#____
 2/25/17
#____
 10/22/16
#____
 3/11/17
#____
 11/12/16
#____
 3/25/17
#____
 11/26/16
#____
 4/8/17
#____
 12/10/16
#____
 4/22/17
#____
 12/17/16
#____
 5/13/17
#____
 1/14/17
#____
 5/27/17
#____
# of sessions ____ x $65 = $_______
Balance Due (Transfer amounts from above)
Hang Time
$
Saturday Respite
$
TOTAL DUE
$
TOTAL ENCLOSED
$
Billing Information
Participant’s full name: ______________________________________________________
Payment source (check all that apply): ____Private pay
____FSS
____Waiver
____Other
If using funds from the Department of Human Services (ODP Waiver) or FSS funds, please provide the following:
County: ______________________
Service Coordinator: _________________________________________ Phone number: _______________________________
I certify that I fully understand that I am personally and completely responsible for any and all payment related to the services
performed by Easter Seals. I understand that this responsibility for payment on my part includes any outside agency subsidies
which are not forthcoming. I agree to pay any and all charges up to the full amount for each session enrolled.
Parent/guardian signature: ___________________________________________________________ Date: ___________________
FOR OFFICE USE ONLY
Date Registered: _____________ Deposit Received: _________
Payment Received: __________ Sent to Allentown: ________
Easter Seals Eastern Pennsylvania
Program Application 2016-2017
Consumer Information
New Consumer
Returning Consumer
Consumer’s Name:____________________________________________________________Sex:_____Height:________Weight:________
Date of Birth: __________________Age: _______ Disability (required): ______________________________________________________
Mailing Address: _____________________________________________City:_________________________State: ______ Zip:__________
County:_________________________________ Home Phone:________________________ Other Phone:__________________________
Email:______________________________________________________________________________(for ESEP news, alerts and updates)
Group Home (if applicable):_____________________________________ Group Home Contact:__________________________________
Legal Guardian:_____________________________________ Home Phone:____________________ Work Phone:____________________
Recent Illness/Injury:_______________________________________________________________________________________________
#1 Responsible Party Information (Guardian or Individual to act as contact person for consumer)
Primary Contact Name:______________________________________________ Relationship to Consumer:_________________________
Mailing Address:_______________________________________________ City:_______________________ State:_____ Zip:___________
Primary Phone:__________________________ Work Phone:_________________________ Other Phone:__________________________
Occupation:____________________________________ Employer:__________________________________________________________
Employer Address:____________________________________________________________Employer Phone:_______________________
Secondary (Emergency) Contact Name:________________________________________ Relationship to Consumer:__________________
Primary Phone:_________________________ Work Phone:__________________________ Other Phone:__________________________
#2 Responsible Party Information (Guardian or Individual to act as contact person for consumer)
Primary Contact Name:__________________________________________ Relationship to Consumer:_____________________________
Mailing Address:_____________________________________________ City:_______________________ State:_______ Zip:___________
Primary Phone:__________________________ Work Phone:__________________________ Other Phone:_________________________
Occupation:________________________________________ Employer:_____________________________________________________
Employer Address:________________________________________________________ Employer Phone:__________________________
Secondary (Emergency) Contact Name:___________________________________ Relationship to Consumer:_________________________
Primary Phone:__________________________ Work Phone:__________________________ Other Phone:_________________________
INFORMATION REQUESTED IS CONFIDENTIAL AND FOR STATISTICAL PURPOSES ONLY
Primary Language: (Please check) _____ English
_____ Spanish
Ethnic Heritage: (Please check all that apply)
_____ African American
_____ Native American
_____ Caucasian
_____ Hispanic or Latino
_____ Decline to Answer
_____ Non-Hispanic or Latino
_____ American Sign Language
_____ Other
_____ Asian/Pacific Islander
_____ Other:__________________________
School District: ________________________________________
Name of School: ________________________________________
Total Number of People Living in Household: _______
For more information and/or to submit your application, please contact or mail to:
Easter Seals Eastern PA
1501 Lehigh St, Suite 201
Allentown, PA 18103-3880
Phone: 610-289-0114 x 402
Katelyn Marte
Email: [email protected]
Fax: 610-289-4282
Visit us online at:
www.easterseals.com/esep